HomeMy WebLinkAboutApp-Permit-ComplianceNo." c-1 s- r� '2 / Y P kev� FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, �/K�I,T- , MA.
APPLICATION FOR=L �®S�L SYSTEM CONSTRUCTION RNIIT
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Application for a Permit to Construct( ) Repair UpgradeO Abandon - ❑ Complete System Individual Components
Location
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Owner's Name
Map/Parcel#
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Address
Lot#
Telephone#
Installer's Name
Designer's Name
Address 0,
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Address
Telephone#(�
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Telephone#
Type of BuildingQ� r Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s)
gpd Calculated design flow
Number of sheets
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
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Design flow provided
Revision Date
Date of Evaluation
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The undersi dr
to ill ve de r�vidual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further s tplace n operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date ? rj T
No. ��i� l�L S" 4 Y �1 ,%rad%/LEE ��
COMMONWEALTH OF MASSACHUSETTS 4f:,qq<
Board of Health, y tm Q l , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: O'Individual Component(s) ElComplete System
The undersigned hereby certyfy that the Se age Disposal System; Constructed ( ), Repaired (/Upgraded Upgraded ( ), Abandoned ( )
by:
at
has been installed
application No.
Installer i c,
9Wac`c`o`r'rd_W/'& wi51he �ov'Sion., of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated -'l- Approved Design Flow (gpd)
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Designer: Inspector4.at
_ l��' `� �'` Date: ,r
The issuance of this permit shall not be construed as a guarthe system willfunction as designed.
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No. 0 C -(S402 8 C. C Sill c- INS P FEE
COMMONWEALTH OF MASSACHUSETTS
Permission is hereby
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Board of Health, i%i0 , MA.
DISPOSAL SYSTEM CNSTRUCTI®N PERMIT
to; Construct( ) --Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No. /C, , dated
Provided: Construction shall be completed within tl -V&4s of the date of this permit. All local conditions must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date 1'- l "" ! Board of Health
No.: BOHDGIS-4428
Commonwealth of Massachusetts F�
555.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Repair-minor-Individual Component(s)
Location: 57 MONROE LN,WEST YARMOUTH, MA 02673 Owner:
LARRABEEIRENEC
Map/Parcel#: 06725 57 MONROE LN
. WEST YARMOUTH,MA 02673
Phone:
SepNc System Installer Designer
BEFORE SUNSET LLC
P.O. BOX 1466 HARWICH, MA 02645
Phone:
Type of Building:Dwelling Lot Siu: 1Q019.00 Acres
Dwelling-No.of Bedrooms:3 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Other Futures:
Plan Date: Number otSheets: Cafeteria:
Title: Revision Date:
Design Flow(min.required):330 gpd Calculated design ilow:330 gpd Desigo flow provided:352 gpd
Description of Soils:
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluatioo:
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-MMOR REPAIR-REPAIR LEAKING SEPTIC TANK
CONNECTED TO DBOX,2-500 GAL PRECAST CHAMBERS W/4'STONE:25'X 13'X 2'
The undersigned agrees W insfall fhe above deaeribed Individual Sewage Disposal System in accoMance wkh the provkions of
TITLE 5 and furfher aarees no[te olace in ooeration until a CertiFicate of Comoliance has been issued 6v the Board of Neakh.
Signed Date
Inspections
i . .
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT ass.00
Permission is hereby granted to;
BEFORE SUNSET LLC, P.O. BOX 1466, HARWICH, MA 02645
To perform: Repair-minor an individual sewage disposal system.
Owner: LARRABEE IRENE C
57 MONROE LN
WEST YARMOUTH,MA 026'I3
Location: 57 MONROE LN, WEST YARMOUTH, MA 02673
Disposal System Construction Permit No.: BOHDGIS-4428 , Dated: September 03,2015
Provided: Construction shall be completed within six months of the date of this permit. All local condirions must be met.
CONDITIONS:
1. SEPTIC DISPOSAL- MINOR REPAIR-REPAIR LEAKING SEPTIC TANK CONNECTED TO DBOX, 2-500 GAL
PRECAST CHAMBERS W/4'STONE: 25'X 13'X 2'
CONDITIONS:
SEPTIC DISPOSAL-MINOR REPAIR-REPAIR LEAKING SEPTIC TANK CONNECTED TO DBOX,
2-500 GAL PRECAST CHAMBERS W/4'STONE: 25'X 13'X 2'
�v�
Bruce G. Murphy P , R.S., CHO/Amy L. von Hone, R.S., CHO
H Ith Director/Assistant Health Director
The issuance of this permit s6a11 not be construed as a guarantee that the system will function as designed.
Commonwealth of Massachusetts
Board of Health, Yarmouth, l�it1 Fee
CERTIFICATE OF COMPLIANCE sss.00
Description of Work: Individual Compooeut(s)
The undersigned hereby certify that the Sewage Disposal System; Repair-minor
by:BEFORE SUNSET LLC
at: 57 MONROE LN,WEST YARMOUTH,MA 02673
Has been installed in accordance with the provisions of 310 CMR 15.00(Title 5)and the approved
design plans or as-built plans relating to application No.: BOHDC-15-4428,dated 09/10/2015.
Installer:BEFORE SUNSET LLC
Address:P.O.BOX 1466 HARWICH,MA 02645 Inspector:AMl'VON HONE,R.S.
Designer:
r � l� /
Bruce G. Murp , MPH, R.S.,CHO/Amy L.v n Hone, R.S., CHO
1' Health Director/Assistant Health Director
The issuance of this permit shall not be construed as a guarantee that the system will funMion as designed.
BOH_Disposal_Construdion_CofC.rpt